Provider Demographics
NPI:1063434116
Name:ELLEBRACHT, SUSAN P (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:P
Last Name:ELLEBRACHT
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:MS
Other - First Name:SUSAN
Other - Middle Name:P
Other - Last Name:ANTONIK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:4016 RAINTREE RD
Mailing Address - Street 2:SUITE 240
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-3700
Mailing Address - Country:US
Mailing Address - Phone:757-488-2864
Mailing Address - Fax:757-488-4735
Practice Address - Street 1:4016 RAINTREE RD
Practice Address - Street 2:SUITE 240
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23321-3700
Practice Address - Country:US
Practice Address - Phone:757-488-2864
Practice Address - Fax:757-488-4735
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202001537235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist